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Dka In Pregnancy Ppt

Michael P. Carson, Md

Michael P. Carson, Md

2004 NJ ACP Obstetric Medicine Workshop Michael P. Carson, MD Asst. Clin. Prof of Medicine and Obstetrics UMDNJ - RWJMS Chief, Division of General Internal Medicine Saint Peter’s University Hospital Common Disorders Asthma – No changes to management Hypothyroidism Check TSH each trimester. Check it 4 weeks after any dosing change SLE – Be very careful. Increased risk of flare RA flares postpartum Multiple Sclerosis – increased flare risk, follow-up period may not be adequate. Background: Pregnancy & DKA Respiratory alkalosis leads to Bicarb loss by kidneys. HCO3- is ~ 20 Less buffering capacity Ketogenesis is accelerated 2-4 times during pregnancy Less hyperglycemia is required to cause DKA during pregnancy Mortality: Maternal 5-15% Fetal 50-90% Diabetic Ketoacidosis Metabolic Effects of DKA Abnormal Insulin:Glucagon ratio favors triglyceride release from adipose tissue. Then, they’re metabolized to ketones rather than being stored or metabolized to carbon dioxide. Notice a theme here? Ketones: Primary is beta-hydroxybutyric acid Aceto acetic acid Reacts with the nitroprusside test. Responsible for fruity odor on the breath. Diabetic Ketoacidosis Glyburide Increases Pancreatic Insulin Output Langer et al. N Engl J Med 2000;343:1134-8 A comparison of glyburide and insulin in women with gestational diabetes mellitus 404 women with GDM requiring treatment Insulin or glyburide between 11-33 weeks Insulin 0.7 U/kg (admission) tid & ï‚ weekly prn Glyburide 2.5 mg/d; ï‚ weekly up to 20 mg/d max. Glyburide Metabolic Outcomes During Treatment Variable Glyburide Insulin P Value (N=201) (N=203) Gestational Age (wks) 28(6 27(8 0.22 Duration of Testing (wks) 10(6 11(7 0.12 Blood Glucose (mg/dl) Fasting 98(13 96(16 0.17 Preprandial 95(15 97(14 Continue reading >>

Diabetes Ketoacidosis In Pregnancy

Diabetes Ketoacidosis In Pregnancy

Abstract Diabetic ketoacidosis (DKA) is a serious medical and obstetrical emergency usually occurring in patients with type 1 (insulin-dependent) diabetes mellitus. Although modern management of the patient with diabetes should prevent the occurrence of DKA during pregnancy, this complication still occurs and can result in significant morbidity and mortality for mother and/or fetus. Metabolic changes occurring during pregnancy can predispose a pregnant diabetic to DKA. The diagnosis of DKA can be more challenging during pregnancy as it does not always manifest with the classic presenting symptoms or laboratory findings. In fact, although uncommon, during pregnancy, DKA may develop even in the setting of relative normoglycemia. Prompt diagnosis and management is essential in order to optimize maternal and fetal outcomes. This article will provide the reader with information regarding the pathophysiology underlying DKA complicating pregnancy and will provide practical management guidelines for the diagnosis and management of this condition. Continue reading >>

Diagnosis And Treatment Of Diabetic Ketoacidosis

Diagnosis And Treatment Of Diabetic Ketoacidosis

85 Abstract Diabetic ketoacidosis (DKA) is the most frequent hyperglycaemic acute diabetic complication. Furthermore it carries a significant risk of death, which can be prevented by early and effective management. All physicians, irrespective of the discipline they are working in and whether in primary, secondary or tertiary care institutions, should be able to recognise DKA early and initiate management immediately. 86 Introduction Diabetic ketoacidosis (DKA) is a common complication of diabetes with an annual occurrence rate of 46 to 50 per 10 000 diabetic patients. The severity of this acute diabetic complication can be appreciated from the high death-to-case ratio of 5 to 10%.1 In Africa the mortality of DKA is unacceptably high with a reported death rate of 26 to 29% in studies from Kenya, Tanzania and Ghana.2 It is a complication of both type 1 and type 2 diabetes mellitus, although more commonly seen in type 1 diabetic patients. Of known diabetic patients presenting with DKA about one-quarter will be patients with type 2 diabetes. In patients presenting with a DKA as first manifestation of diabetes about 15% will be type 2.3 This correlates well with data from South Africa suggesting that one- quarter of patients with DKA will be type 2 with adequate C-peptide levels and the absence of anti-GAD antibodies.4 This review will focus on the principles of diagnosis, monitoring and treatment of DKA, with special mention of new developments and controversial issues. Clinical features DKA evolves over hours to days in both type 1 and type 2 diabetic patients, but the symptoms of poor control of blood glucose are usually present for several days before the onset or presentation of ketoacidosis.5 The clinical features of DKA are non-specific and patients may present with Continue reading >>

Diabetic Ketoacidosis In Pregnancy

Diabetic Ketoacidosis In Pregnancy

The occurrence of diabetic ketoacidosis in pregnancy compromises both the fetus and the mother. It usually occurs in the later stages of pregnancy and is also seen in newly presenting type 1 diabetes patients. Despite improvement in its incidence rates and outcomes over the years, it still remains a major clinical problem since it tends to occur at lower blood glucose levels and more rapidly than in non-pregnant patients often causing delay in the diagnosis. This article illustrates a typical case of diabetic ketoacidosis in pregnancy and reviews the literature to provide an insight into its pathophysiology and management. Full Text Selected References These references are in PubMed. This may not be the complete list of references from this article. Continue reading >>

Diabetes Ketoacidosis

Diabetes Ketoacidosis

1. DIABETIC KETO-ACIDOSIS MANAGEMENT 2. INTRODUCTION  HHS and DKA are not mutually exclusive but rather two conditions that both result from some degree of insulin deficiency.  They can and often do occur simultaneously. In fact, one third of patients admitted for hyperglycemia exhibit characteristics of both HHS and DKA. 14th edition of Joslin's Diabetes Mellitus 3. DEFINITION DKA is defined as the presence of all three of the following: (i) Hyperglycemia (glucose >250 mg/dL) (ii) Ketosis, (iii) Acidemia (pH <7.3). 14th edition of Joslin's Diabetes Mellitus 4. PATHOPHYSIOLOGY Insulin Deficiency Glucose uptake Lipolysis Proteolysis Glycerol Free Fatty Acids Amino Acids Hyperglycemia Osmotic diuresis Ketogenesis Gluconeogenesis Glycogenolysis Dehydration Acidosis 14th edition of Joslin's Diabetes Mellitus 5. ROLE OF INSULIN  Required    for transport of glucose into: Muscle Adipose Liver  Inhibits lipolysis  Absence of insulin Glucose accumulates in the blood.  Uses amino acids for gluconeogenesis  Converts fatty acids into ketone bodies : Acetone, Acetoacetate, β-hydroxybutyrate.  6. DIABETIC KETOACIDOSIS PRECIPITATING EVENTS  Infection(Pneumonia / UTI / Gastroenteritis / Sepsis)  Inadequate insulin administration  Infarction(cerebral,  Drugs coronary, mesenteric, peripheral) (cocaine)  Pregnancy. Harrison’s Principle of internal medicine 18th edition p2977 7. SYMPTOMS DKA PHYSICAL FINDINGS can be the first Dehydration/hypotension presentation. Tachypnea/kussmaul Nausea/vomiting Thirst/polyuria Abdominal pain Shortnessof Tachycardia breath respirations/respiratory distress Fruity odour in breath. Abdominal tenderness(may resemble acute pancreatitis or surgical abdomen) Lethargy/obtundati Continue reading >>

Exam Shows Diffuse Abdominal Tenderness With Guarding.

Exam Shows Diffuse Abdominal Tenderness With Guarding.

A 14 y/o female is brought to the emergency department by her mother after being found unresponsive at home. She had been ill the day before with nausea and vomiting, but was not running a fever. Her parents had kept her home from school that day. When her mother came home at lunchtime to check on her, she was very lethargic and not responding coherently. By the time she arrived at the hospital, she had to be brought in to the ED on a gurney. Initial evaluation showed O2 sat 100% on room air, pulse 126, respirations 30, BP 92/68, temperature 101.2 F. She appears pale, mucous membranes are dry and she only responds to painful stimuli. Exam shows diffuse abdominal tenderness with guarding. Differential diagnosis? What initial treatment would you suggest? What labs would you order? Any xrays or additional studies? CBC WBC 23,500 Hgb 14.2 g/dL Hct 45% Platelets 425,000 BMP Sodium 126 Potassium 5.2 Chloride 87 CO2 <5 BUN 32 Creatinine 1.5 Glucose 1,376 Arterial Blood Gases pH 7.19 Po2 100 mm Hg HCO3 7.5 mmo/L Pco2 20 mm Hg Sao2 98% (room air) Urine Specific gravity 1.015 Ketones 4+ Leukocytes few Glucose 4+ Nitrates 0 RBCs many Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. DKA occurs mostly in type 1 diabetics. It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. Symptoms and signs of DKA Nausea & vomiting Abdominal pain--particularly in children Lethargy and somnolence Kussmaul respirations Hypotension Tachycardia Fruity breath Continue reading >>

Canadian Diabetes Association Clinical Practice Guidelines Hyperglycemic Emergencies In Adults

Canadian Diabetes Association Clinical Practice Guidelines Hyperglycemic Emergencies In Adults

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1 Clinical Practice Guidelines CPG Tool Kit Professional Publications Diabetes Educator Study Resources & Educator Resources Food and Nutrition Tools CDA-CSEM Annual Conference Key Points Suspect DKA or HHS in an ill patient with hyperglycemia (usually) – medical emergency DKA = ketoacidosis is prominent HHS = ECFV contraction + hyperosmolarity Rx = FLUIDS, POTASSIUM, INSULIN (DKA) Treat precipitating cause Prevention is critical 2013 guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 2 Clinical Practice Guidelines CPG Tool Kit Professional Publications Diabetes Educator Study Resources & Educator Resources Food and Nutrition Tools CDA-CSEM Annual Conference Hyperglycemic Emergencies DKA = Diabetic Ketoacidosis HHS = Hyperosmolar Hyperglycemic State Common features: Insulin deficiency ïƒ hyperglycemia ïƒ urinary loss of water and electrolytes ïƒ Volume depletion + electrolyte deficiency + hyperosmolarity Insulin deficiency (absolute) + glucagon ïƒ Ketoacidosis (in DKA) guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 3 Clinical Practice Guidelines CPG Tool Kit Professional Publications Diabetes Educator Study Resources & Educator Resources Food and Nutrition Tools CDA-CSEM Annual Conference DKA Ketoacidosis ECFV contraction Milder hyperosmolarity Normal to high glucose May haveLOC Beware hypokalemia Must use insulin Absolute insulin deficiency + glucagon HHS Minimal acid-base problem ECFV contraction Hyperosmolarity Marked hyperglycemia Marked LOC Beware hypokalemia May need insulin Relative insulin Continue reading >>

Chapter 11: Diabetic Ketoacidosis In Pregnancy

Chapter 11: Diabetic Ketoacidosis In Pregnancy

Despite recent advances in the evaluation and medical treatment of diabetes in pregnancy, diabetic ketoacidosis (DKA) remains a matter of significant concern. The fetal loss rate in most contemporary series has been estimated to range from 10% to 25%. Fortunately, since the advent and implementation of insulin therapy, the maternal mortality rate has declined to 1% or less. In order to favorably influence the outcome in these high-risk patients, it is imperative that the obstetrician/provider be familiar with the basics of the pathophysiology, diagnosis, and treatment of DKA in pregnancy. DKA is characterized by hyperglycemia and accelerated ketogenesis. Both a lack of insulin and an excess of glucagon and other counter-regulatory hormones significantly contribute to these problems and their resultant clinical manifestations. Glucose normally enters the cell secondary to the effects of insulin. The cell then may use glucose for nutrition and energy production. When insulin is lacking, glucose fails to enter the cell. The cell responds to this starvation by facilitating the release of counter-regulatory hormones, including glucagon, catecholamines, and cortisol. These counter-regulatory hormones are responsible for providing the cell with an alternative substrate for nutrition and energy production. By the process of gluconeogenesis, fatty acids from adipose tissue are broken down by hepatocytes to ketones (acetone, acetoacetate, and β-hydroxybutyrate [BHB] = ketone bodies), which are then used by the body cells for nutrition and energy production (Fig. 11-1). The lack of insulin also contributes to increased lipolysis and decreased reutilization of free fatty acids, thereby providing more substrate for hepatic ketogenesis. A basic review of the biochemistry involving D Continue reading >>

Department Of Endocrinology, Diabetes, Metabolism

Department Of Endocrinology, Diabetes, Metabolism

Dr. Kanakamani Madhivanan, M.D., D.M. (Endocrinology), Assistant Professor Christian Medical College, Vellore Introduction Global increase in prevalence of DM Individual importance - Hyperglycemia in pregnancy has adverse effects on both mother and fetus Public health importance – rising epidemic of DM in part attributed to the diabetic pregnancies Prevention of type 2 DM should start intrauterine and continue throughout life Introduction Gestational diabetes (GDM) is defined as any degree of impaired glucose tolerance of with onset or first recognition during pregnancy . Many are denovo pregnancy induced Some are type 2 ( 35-40%) 10% have antibodies Introduction Difficult to distinguish pregestational Type 2 DM and denovo GDM Fasting hyperglycemia blood glucose greater than 180 mg/dL on OGT acanthosis nicgrans HbA1C > 5.3% a systolic BP > 110 mm Hg BMI > 30 kg/m2 Fetal anomalies Clues for Type 1 Lean DKA during pregnancy Severe hyperglycemia with large doses of insulin Fuel metabolism in pregnancy Goal is uninterrupted nutrient supply to fetus The metabolic goals of pregnancy are 1) in early pregnancy to develop anabolic stores to meet metabolic demands in late pregnancy 2) in late pregnancy to provide fuels for fetal growth and energy needs. Glucose metabolism in pregnancy Early pregnancy E2/PRL stimulates b cells –Insulin sensitivity same and peripheral glucose utilisation – 10% fall in BG levels Late pregnancy Fetoplacental unit extracts glucose and aminoacids, fat is used mainly for fuel metabolism Insulin sensitivity decreases progressively upto 50-80% during the third trimester variety of hormones secreted by the placenta, especially hPL and placental growth hormone variant, cortisol, PRL,E2 and Prog Glucose metabolism in pregnancy Fetus Fat Continue reading >>

Diabetic Ketoacidosis In Pregnancy ( Ahmed Walid Anwar Morad)

Diabetic Ketoacidosis In Pregnancy ( Ahmed Walid Anwar Morad)

1. Management of diabetic ketoacidosis in pregnancy Dr/ Ahmed Walid Anwar Morad Assistant professor of OB/GYN Benha University 2017 2. This talk spotlights on • Definition • Epidemiology • Pathophysiology • Diagnosis • Differential diagnosis • Prevention • Treatment • Pitfalls in DKS 3. Epidemiology • DKA is an acute medical emergency associated with: - Fetal loss rates more than 50%. - Maternal mortality rates less than 1%. 4. Epidemiology • DKA in pregnancy most commonly occurs in women with: - Poorly controlled : *T1DM *T2DM or GDM under - Glucocorticoids - B-agonists / tocolytics - First presentation of T1DM in pregnancy 6. Glucose Homeostasis 7. DKA is common during pregnancy WHY? • Pregnancy is a stat of Relative insulin resistance especially in 2nd & 3rd trimesters. • Increased levels of HPL ,E, P & Cortisol act as insulin antagonists& impair maternal insulin sensitivity. • Pregnancy is a state of respiratory alkalosis associated with a compensatory drop in bicarbonate levels; this impairs the renal buffering capacity. 8. Precipitating factors of DKA in pregnancy • Insufficient or no insulin • Protracted vomiting • Hyperemesis gravidarum • Starvation • Infections • Medications precipitating DKP • Conditions such as diabetic gastroparesis 9. Diagnosis of DKA in pregnancy • DKP may be the first presentatio n of diabetes in pregnancy 10. Laboratory confirmation of DKA in pregnancy 11. Pitfalls in DKA • Potassium level may be falsely normal/elevated. • High – WBC count without infection. – Blood urea with prerenal azotemia due to dehydration. – Creatinine in absence of true impairment of renal function. – Serum amylase even in absence of pancreatitis. 12. What is different in pregnancy? • DKA occurs at lower blo Continue reading >>

Diabetes Mellitus And Pregnancy

Diabetes Mellitus And Pregnancy

Practice Essentials Gestational diabetes mellitus (GDM) is defined as glucose intolerance of variable degree with onset or first recognition during pregnancy. A study by Stuebe et al found this condition to be associated with persistent metabolic dysfunction in women at 3 years after delivery, separate from other clinical risk factors. [1] Infants of mothers with preexisting diabetes mellitus experience double the risk of serious injury at birth, triple the likelihood of cesarean delivery, and quadruple the incidence of newborn intensive care unit (NICU) admission. Gestational diabetes mellitus accounts for 90% of cases of diabetes mellitus in pregnancy, while preexisting type 2 diabetes accounts for 8% of such cases. Screening for diabetes mellitus during pregnancy Gestational diabetes The following 2-step screening system for gestational diabetes is currently recommended in the United States: Alternatively, for high-risk women or in areas in which the prevalence of insulin resistance is 5% or higher (eg, the southwestern and southeastern United States), a 1-step approach can be used by proceeding directly to the 100-g, 3-hour OGTT. The US Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes mellitus after 24 weeks of pregnancy. The recommendation applies to asymptomatic women with no previous diagnosis of type 1 or type 2 diabetes mellitus. [2, 3] The recommendation does not specify whether the 1-step or 2-step screening approach would be preferable. Type 1 diabetes The disease is typically diagnosed during an episode of hyperglycemia, ketosis, and dehydration It is most commonly diagnosed in childhood or adolescence; the disease is rarely diagnosed during pregnancy Patients diagnosed during pregnancy most often present with unexpected Continue reading >>

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